﻿<%@ Page Title="" Language="C#" MasterPageFile="~/common/Admin.master" AutoEventWireup="true" CodeFile="applicant_details_hospital.aspx.cs" Inherits="product_insurance_admin_applicant_details_hospital" %>


<asp:Content ID="Content3" ContentPlaceHolderID="leftMenu" runat="Server">
<ul>
     <li><a href="<%= Page.ResolveUrl("~/product/saving/admin/saving_apply.aspx")%>">
       Open Saving Account</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/card/admin/PendingApplication.aspx")%>">
        Debit Card Applicant List</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/admin/insurance_applicant_list.aspx")%>">
        Insurance Applicant List</a></li>
  
                   
    </ul>
</asp:Content>
<asp:Content ID="Content4" ContentPlaceHolderID="content" runat="Server">
    <h1>Power Saver Hospitalisation Applicant Details</h1>
    <asp:HiddenField ID="applicationID" runat="server" />
    <asp:HiddenField ID="custId" runat="server" />
    
    
            <fieldset>
                <legend>Particulars of Personal to be Insured</legend>
                <asp:FormView ID="Self_FormView" runat="server" Width="718px">
        <ItemTemplate>
                <table id="gg_app_parent" class="style2">
                    <tr>
                        <td class="style18">First name:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_fname" runat="server" Text='<%# Bind("fName") %>' Font-Bold="True" ForeColor="#0066FF"></asp:Label>
                        </td>
                        <td class="style19">Last name:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_lname" runat="server" Text='<%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td class="style18">NRIC:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_nric" runat="server" Text='<%# Bind("NRIC") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td class="style19">Nationality:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_nationality" runat="server" Text='<%# Bind("nationality") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td class="style18">Gender:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_gender" runat="server" Text='<%# Bind("gender") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td class="style19">Marital status:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_maritalStatus" runat="server" Text='<%# Bind("marital") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td class="style18">Date of Birth:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_dob" runat="server" Text='<%# Bind("birth") %>' Font-Bold="True" ForeColor="#0066FF"></asp:Label>
                        </td>
                        <td class="style19">Occupation:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_occupation" runat="server" Text='<%# Bind("occupation") %>' Font-Bold="True" ForeColor="#0066FF"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td class="style18">Relationship to<br />
                            the person to<br />
                            be insured:
                  
                    
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_localPeriod" runat="server" Text='<%# Bind("relationShip") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td class="style19" />
                        <td class="style20" />
                    </tr>
                    <tr>
                        <td class="style18">Tel(H):
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_tel" runat="server" Text='<%# Bind("telephone") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td class="style19">Mobile:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_mobile" runat="server" Text='<%# Bind("mobile") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td class="style18">Email:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_email" runat="server" Text='<%# Bind("email") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td colspan="2"></td>
                    </tr>
                    <tr>
                        <td class="style18">Mailing Address:
                        </td>
                        <td class="style17">
                            <asp:Label ID="lb_address" runat="server" Text='<%# Bind("address") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td class="style19">Postal code:
                        </td>
                        <td class="style20">
                            <asp:Label ID="lb_postal" runat="server" Text='<%# Bind("postalCode") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    
                </table>
                </ItemTemplate>
    </asp:FormView>
                <asp:Label ID="lb_link_view" runat="server" Text="Customer foreigner attachment:"></asp:Label>
             <asp:HyperLink ID="link_view" runat="server" Text="View" Target="_blank" />
            


            </fieldset>

        


    <fieldset>
        <legend>Particulars of Family Members to be Insured</legend>
        <table class="style1">

            <tr>
                <td class="style33">&nbsp;
                </td>
                <td class="style36">First name&nbsp;
                </td>
                <td class="style37">Last name
                </td>
                <td class="style38">NRIC/FIN/BC
                    <br />
                    No.
                </td>
                <td class="style23">Date of birth<br />
                    (dd/mm/yyyy
                </td>
                <td class="style35">Gender
                </td>
                <td class="style21">Height<br />
                    &nbsp; (m)
                </td>
                <td class="style32">Weight<br />
                    &nbsp;(kg)
                </td>
                <td>Smoke<br />
                </td>
            </tr>
            <asp:Repeater ID="Relation_Repeater" runat="server">
                <ItemTemplate>
                    <tr>
                        <td class="style33">
                            <%# Eval("relationship")%> :
                        </td>
                        <td class="style36">
                            <asp:Label ID="lbs_fname" runat="server" Font-Bold="True" ForeColor="#0066FF"><%# Eval("fName")%></asp:Label>
                        </td>
                        <td class="style37">
                            <asp:Label ID="lbs_lname" runat="server" ForeColor="#0066FF" Font-Bold="True"><%# Eval("lName")%></asp:Label>
                        </td>
                        <td class="style38">
                            <asp:Label ID="lbs_nric" runat="server" Font-Bold="True" ForeColor="#0066FF"><%# Eval("NRIC")%></asp:Label>
                        </td>
                        <td class="style23">
                            <asp:Label ID="lbs_dob" runat="server" ForeColor="#0066FF" Font-Bold="True"><%# Eval("birth")%></asp:Label>
                        </td>
                        <td class="style35">
                            <asp:Label ID="lbs_gender" runat="server" Font-Bold="True" ForeColor="#0066FF"><%# Eval("gender")%></asp:Label>
                            &nbsp;<br />
                        </td>
                        <td class="style21">
                            <asp:Label ID="lbs_h" runat="server" Font-Bold="True" ForeColor="#0066FF"><%# Eval("height")%></asp:Label>
                        </td>
                        <td class="style32">
                            <asp:Label ID="lbs_w" runat="server" ForeColor="#0066FF" Font-Bold="True"><%# Eval("weight")%></asp:Label>
                        </td>
                        <td>
                            <asp:Label ID="lbs_s" runat="server" Font-Bold="True" ForeColor="#0066FF"><%# Eval("isSmoker")%></asp:Label>
                            <br />
                        </td>
                    </tr>
                </ItemTemplate>
            </asp:Repeater>


        </table>


    </fieldset>
    <asp:FormView ID="Employee_FormView" runat="server" Width="715px">
        <ItemTemplate>
            <fieldset>
                <legend>Details of Employer</legend>

                <table id="tbl_employerDetail" class="style1">
                    <tr>
                        <td>Name of Employer:</td>
                        <td class="style9">
                            <asp:Label ID="lbe_name" runat="server" Text='<%# Bind("employerName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td>Address of Employer:</td>
                        <td class="style9">
                            <asp:Label ID="lbe_address" runat="server" Text='<%# Bind("employerAddress") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                    <tr>
                        <td>Nature of Employer’s Business:</td>
                        <td class="style9">
                            <asp:Label ID="lbe_business" runat="server" Text='<%# Bind("business") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>
                </table>

            </fieldset>
        </ItemTemplate>
    </asp:FormView>
    <fieldset>
        <legend>Questionnaire</legend>

        <table class="style10">
            <tr>
                <td>
                    <asp:Label ID="lbq1_disease" runat="server" Text="1.&nbsp;Has any one of the applicants ever had or been told to have, or currently 
                    undergoing any medical treatment for,ever been treated for, under observation 
                    for,any disease, infirmity, illness or physical defect?"></asp:Label>
                    <br />
                    &nbsp;
                    <br />
                    <asp:Label ID="lbq2_surgical" runat="server" Text="2. &nbsp;Has any one of the applicants ever,<br />(a) had a surgical operation?<br />(b) been advised to have any diagnostic test, hospital confinement or surgical operation which has not yet been performed? "></asp:Label>
                    <br />
                    <br />
                </td>
            </tr>
            <tr>
                <td>If the answer to any of the above questions is YES, please provide details 
                    below. If surgery is undertaken, please provide name/nature of surgical 
                    procedure.<br />

                    <table class="style24">
                        <tr>
                            <td class="style25">Name of Person</td>
                            <td class="style19">Nature of Illness/<br />
                                &nbsp;Disability</td>
                            <td>Date &amp; Duration of Disability</td>
                            <td>Type &amp; Result of Treatment/ Surgery</td>
                            <td>Name &amp; Address
                                <br />
                                of Doctor, Clinic/Hospital</td>
                        </tr>

                        <asp:Repeater ID="IllNess_Repeater" runat="server">
                            <ItemTemplate>
                                <tr>
                                    <td class="style25">
                                        <asp:Label ID="lb_name1" runat="server" Text='<%# Bind("fName") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td class="style19">
                                        <asp:Label ID="lb_nature1" runat="server" Text='<%# Bind("illness") %>' Font-Bold="True" ForeColor="#0066FF"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lb_duration1" runat="server" Text='<%# Bind("illDuration") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lb_result1" runat="server" Text='<%# Bind("illTreatment") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lb_address1" runat="server" Text='<%# Bind("illhospital") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                </tr>
                            </ItemTemplate>
                        </asp:Repeater>
                    </table>
                    <br />
                </td>
            </tr>
            <tr>
                <td>&nbsp;<asp:Label ID="lbq3_declined" runat="server" Text="3.Has any one of the applicants ever,<br />(a) had an Accident or Health insurance policy cancelled or its renewal refused?<br />(b) had a Life, Accident or Health insurance policy declined, postponed, withdrawn or subject to special terms and conditions?<br />(c) made a claim against any Insurer in respect of bodily injury or sickness? "></asp:Label>
                    If the answer to any of the questions is YES, please give details:<br />
                </td>
            </tr>
            <tr>
               <td>

            <table class="style8">
                        <asp:Repeater ID="DeclinedHistory_Repeater" runat="server">
                            <HeaderTemplate>
                                <tr>
                                    <td>
                                        Full Name
                                    </td>
                                    <td>
                                        Details
                                    </td>
                                </tr>
                            </HeaderTemplate>
                            <ItemTemplate>
                                <tr>
                                    <td>
                                        <asp:Label ID="lbq4_name1" runat="server" Text='<%# Bind("fName") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lbq4_declinedHistory1" runat="server" Text='<%# Bind("DeclinedHistory") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                </tr>
                            </ItemTemplate>
                        </asp:Repeater>
                    </table>
                    </td>
            </tr>
            
            <tr>
                <td colspan="2">4. Is there any known or foreseeable need to consult any doctor or other health 
                    professional?
                    <br />
                    If YES, please give details:<br />
                </td>
            </tr>
            <tr>
                <td class="style39">Full Name
                </td>
                <td>Details
                </td>
            </tr>
            <asp:Repeater ID="Foreseeable_Repeater" runat="server">
                <ItemTemplate>
                    <tr>
                        <td>
                            <asp:Label ID="lbq4_name1" runat="server" Text='<%# Bind("fName") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                        <td>
                            <asp:Label ID="lbq4_foreseeableIllness1" runat="server" Text='<%# Bind("foreseeable") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                        </td>
                    </tr>

                </ItemTemplate>
            </asp:Repeater>
        </table>

    </fieldset>
    <fieldset>
        <legend>Raised Blood Pressure / Hyperlipidaemia (high cholesterol)</legend>


        <table class="style1">
            <tr>
                <td>

                    <br />
                    Applicable only to applicants who have ever had or been told to have, or 
                    currently undergoing any medical treatment for, ever been treated for, under 
                    observation for, Raised Blood Pressure/ Hyperlipidaemia (high cholesterol).<br />
                    Please provide the latest blood pressure and cholesterol reading and date.<br />
                    <br />
                    A. Raised Blood Pressure<br />
                    <table class="style24">
                        <asp:Repeater ID="Repeater1" runat="server">
                            <HeaderTemplate>
                                <tr>
                                    <td class="style29">Name of Person</td>
                                    <td class="style29">Systolic &amp;
                                <br />
                                        Diastolic Reading</td>
                                    <td class="style29">Date of<br />
                                        Reading</td>
                                    <td class="style29">Name &amp; address of Doctor,
                                <br />
                                        Clinic/Hospital</td>
                                </tr>
                            </HeaderTemplate>
                            <ItemTemplate>
                                <tr>
                                    <td>
                                        <asp:Label ID="lbhbp_name1" runat="server" Text='<%# Bind("fName") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lbhbp_reading1" runat="server" Text='<%# Bind("bloodPressureIllSystolic") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lbhbp_date1" runat="server" Text='<%# Bind("bloodPressureIllDate") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                    <td>
                                        <asp:Label ID="lbhbp_address1" runat="server" Text='<%# Bind("bloodPressureIllHospital") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                                    </td>
                                </tr>

                            </ItemTemplate>
                        </asp:Repeater>
                    </table>
                </td>
            </tr>
            <tr>
                <td>B. Hyperlipidaemia (high cholesterol)<br />
                    <table class="style24">
                        <asp:Repeater ID="Hyperlipidaemia_Repeater" runat="server">
                            <HeaderTemplate>
                                <tr>
                            <td>Name of Person</td>
                            <td>Total Cholesterol Level<br />
                                (Tchol)</td>
                            <td>Date of<br />
                                Reading</td>
                            <td>Name &amp; address of Doctor,
                                <br />
                                Clinic/Hospital</td>
                        </tr>
                            </HeaderTemplate>
                            <ItemTemplate>
                            <tr>
                            <td>
                                <asp:Label ID="lbhc_name1" runat="server" Text='<%# Bind("fName") %> <%# Bind("lName") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                            </td>
                            <td>
                                <asp:Label ID="lbhc_level1" runat="server" Text='<%# Bind("HyperlipidaemiaLevel") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                            </td>
                            <td>
                                <asp:Label ID="lbhc_date1" runat="server" Text='<%# Bind("HyperlipidaemiaDate") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                            </td>
                            <td>
                                <asp:Label ID="lbhc_address1" runat="server" Text='<%# Bind("HyperlipidaemiaHospital") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                            </td>
                        </tr>

                            </ItemTemplate>
                        </asp:Repeater>
                    </table>
                </td>
            </tr>
        </table>
    </fieldset>
    <fieldset>
        <legend>Details of Insurance</legend>
        <table class="style2">
            <tr>
                <td>Period of Insurance
                </td>
            </tr>
            <tr>
                <td>Insurance to commence: From
                    <asp:TextBox ID="tbStartDate" runat="server"></asp:TextBox>
                    &nbsp;to
                    <asp:TextBox ID="tbEndDate" runat="server"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td>
                     <table class="style24">
                        <asp:Repeater ID="Plan_Repeater" runat="server">
                            <HeaderTemplate>
                              <tr>
                            <td class="style28">&nbsp;</td>
                            <td class="style27">Plan Selected</td>
                            <td>Premium Level</td>
                            <td></td>
                        </tr>
                            </HeaderTemplate>
                            <ItemTemplate>
                             <tr>
                            <td style="color:#0066FF; font-weight:bold;"><%# Eval("fName") %><%# Eval("lName") %></td>
                            <td style="color:#0066FF; font-weight:bold;"><%# Eval("planType") %></td>
                                 <td>
                                     <asp:DropDownList ID="ddlPremiumLevel" runat="server">
                                         <asp:ListItem Value="1">Level 1</asp:ListItem>
                                         <asp:ListItem Value="2">Level 2</asp:ListItem>
                                         <asp:ListItem Value="3">Level 3</asp:ListItem>
                                         <asp:ListItem Value="4">Level 4</asp:ListItem>
                                         <asp:ListItem Value="5">Level 5</asp:ListItem>
                                     </asp:DropDownList>
                                 </td>
                                 <td><asp:CheckBox ID="cb_accept" runat="server" />
                                  <asp:HiddenField ID="hf_insuredId" runat="server" Value='<%# Eval("insuredId") %>'/></td>
                                
                        </tr>

                            </ItemTemplate>
                        </asp:Repeater>
                    </table>
                </td>
            </tr>
            <tr>
                <td>&nbsp;
                </td>
            </tr>
        </table>

    </fieldset>
    <fieldset>
        <legend>Payment Method</legend>
        <table class="style2">
            <tr>
                <td>Payment Period:
                  
                </td>
                <td>
                    <asp:Label ID="lb_paymentPeriod" runat="server" Text='<%# Bind("paymentPeriod") %>' ForeColor="#0066FF" Font-Bold="True"></asp:Label>
                </td>
            </tr>
           
            <tr>
                <td>
                    <asp:Button ID="btnSubmit" runat="server" Text="Accept"
                        OnClick="btnSubmit_Click" />
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                    <asp:Button ID="btnReset" runat="server" Text="Reject" />
                </td>
            </tr>
        </table>
        <br />

    </fieldset>

</asp:Content>

<asp:Content ID="Content5" runat="server" contentplaceholderid="html_js">
<script type="text/javascript">
    $(document).ready(function () {
        $("#content_content_tbStartDate").datepicker({ dateFormat: 'dd/mm/yy' });

        $('#content_content_tbStartDate').change(function () {
            autoEndYear();
        });

    });


    function autoEndYear() {
        startDay = $('#content_content_tbStartDate').val();
        if (startDay == "") {
            return;
        }


        var dateStr = startDay.split("/");
        var year = (parseInt(dateStr[2]) + 1);
        var endYear = dateStr[0] + "/" + dateStr[1] + "/" + year;
        $('#content_content_tbEndDate').val(endYear);
    }
    </script>
 
</asp:Content>


